KAFO
  • Legacy form will be accepted until Nov 1st. Access Legacy PDF work orders below:

    KAFO METAL KAFO

     

  • Please do not print the Review page.

    Scroll to the bottom, hit Complete and then download the work order. 

  • KAFO

    Intake Information
  • Format: (000) 000-0000.
    • Patient/Device Information: 
    • Bilateral:*
    • Bilateral Type:*
    • Affected Side:*
    • Bilateral Symmetrical: 

      • Left and Right sides can have different Measurements
      • Same Alignment, Design and Finishing options
    • Weight Unit:
    • Submission Type:

      • Plaster Cast: Negative or Positive

        Please include a printed Work Order with the cast when shipping.
    • Device Design:

    • Thigh Options:*
    • Calf Options:*
    • Foot Options:*
    • The Shipping section is now at the end of the form.

    • Scan being submitted with order:*
    • The Scan Upload is available at the end of the Form. 

    • Is this a Hanger3D app scan?*
      • Please complete this form. Next, after acquiring the scan via the Hanger3D app, go to Order Forms > Jotform Order and fill out the required information and submit the scan. NO OTHER ACTION IS NEEDED

        

    • Scan Type:*
    • The Cast Measurement fields are available at the end of the Form. 

    • Due to the scan being modified, the Alignment and Modification options will not be displayed.

      Any Alignment or Modification changes can be called out in the Notes section. 

    • Raven Base Code:
  • KAFO

    Configurator
  • 0/250
  • Please indicate measurement unit:*
    • Measurements: 
    • Patient Measurements
    • Patient Measurements
    • Alignment: 
    • i

      NEUTRAL is the Tibia perpendicular to the floor based on Heel Height. 

    • Ankle Alignment:*
    • Final Ankle Position:

    • Set the Ankle in   *   ° of      *        

    • Heel Height Accommodation:*
    • Forefoot Alignment:*
    • Final Forefoot Position:

    • Set the Forefoot in   *   ° of      *        

    • Hindfoot Alignment:*
    • Final Hindfoot Position:

    • Set the Hindfoot in   *   ° of      *        

    • Sagittal Knee Alignment:*
    • Final Knee Position (Sagittal Plane):

    • Set the Knee in   *   ° of      *              

    • Coronal Knee Alignment:*
    • Final Knee Position (Coronal Plane):

    • Set the Knee in   *   ° of      *                    

    • Modifications/Trimlines: 
    • Tone Reducing Modifications:
    • Image field 1232
    • Image field 1233
    • Buildups/Reductions:
    • Standard Mods include:

      • 1/8" (3 mm) buildup at the Malleoli, Navicular and Base of the 5th. 
      • 1/8" (3 mm) reduction at the Medial Longitudinal Arch Apex. 
    • Met Heads:
    • Medial Malleolus:
    • Lateral Malleolus:
    • Navicular:
    • Base of the 5th:
    • Posterior Heel (pump bump):
    • Medial Longitudinal Arch Apex Reduction:
    • Image field 1047
    • Image field 1048
    • Foot Mod Add ons:
    • Intrinsic Heel Skive:*
    • Skive Magnitude:*
    • Intrinsic Heel Skive requires external posting/wedging.

    • i

      Standard Default: 1/8" deflection at Malleoli away from the leg to reduce edge pressure

    • Brim Profile:*
    • Image field 1185
    • Image field 1186
      • Standard: 1/8" deflection from the leg with extra accommodation at the malleoli to reduce edge pressure.
      • Gutter: Material added to create a "gutter" shape so the trimlines are inline with the apex of the buildups. (Commonly used for Positioning or Night time Stretching AFOs).
    • Midfoot Trimline Default:
    • Image field 1106
    • Midfoot Trimline:
    • Plastic Footplate Trimline Default:
    • Provided Finished Foot Plate Length: {finishedPlastic1000}{finishedPlastic999}

    • Footplate Trimline:
    • Forefoot Trimline Default:
    • Forefoot Trimline:
    • Image field 1049
    • Thigh Add-Ons:
    • Thigh Tongue Material:*
    • Image field 1050
    • Image field 1064
    • Calf Add-Ons:
    • Anterior Shell Type:*
    • Calf Tongue Material:*
    • Left Supramalleolar Extension:*
    • Right - Supramalleolar Extension:*
    • Knee Extension:
    • Left Knee Extension Type:*
    • Right Knee Extension Type:*
    • Materials/Design: 
    • Posting/Wedging:

    • Shoes:
    • {intrinsicHeel990} Intrinsic Heel Skive was selected.

    • Heel Post:
    • Heel Post Material:*
    • Image field 1119
    • Image field 1120
    • Image field 1121
    • External Forefoot Post:
    • External Forefoot Post Material:*
    • Image field 1122
    • Image field 1123
    • Image field 1138
    • Knee Joints

    • Uprights:*
    • Single Upright:*
    • Knee Joint Type:*
    • Single Axis Lock Type:*
    • Posterior Offset Lock Type:*
    • Bail Lock:
    • Step Lock:
    • Options:
    • Ankle Joints

    • Joints:*
    • Joints:*
    • Tamarack w/Dorsiflexion Assist:*
    • Preset:
    • Flexion Type:*
    • Stirrup:*
    • Posterior Stop:*
    • Image field 1299
    • Image field 1294
    • Image field 1295
    • Image field 1296
    • Image field 1297
    • Bar:

    • Please select the appropriate bar size based on patient weight, activity level and joint type. 

    • Bar Material:*
    • Bar Size:*
    • Bar Size:*
    • Plastic

    • i

      Finished Plastic Thickness will be within 10% of the requested thickness. 

    • Plastic Type:*
    • Finished Plastic Thickness:*
    • Finished Plastic Thickness:*
    • Plastic Color/Transfer:*
    • Special Order Transfer Papers can increase device turnaround time.

    • Stocked Transfers Container #1
    • Friddles Transfers Container #1
    • Stocked Transfers Container #2
    • Friddles Transfers Container #2
    • PLEASE SELECT DIFFERENT OPTIONS FOR TRANSFER PAPERS.

    • Reinforcement:
    • Inner Boot:
    • Inner Boot Thickness:*
    • Inner Boot Thickness:*
    • Image field 1082
    • Padding: 
    • Metal Band Padding Thickness:*
    • Anterior Shell Padding Thickness:*
    • Full Device Padding Thickness:*
    • Supramalleolar Ext. Padding Thickness:*
    • Plantar Surface Padding Thickness:*
    • Additional Padding

    • Malleoli Padding:
    • Malleoli Padding Thickness:*
    • Calf Padding Thickness:*
    • Navicular Padding Thickness:*
    • Additional Padding Insertion:
    • Finishing: 
    • Upright Fastener Type:*
    • Strap Fastener Type:*
    • Strap Type:*
    • Strap Type:*
    • Leather Strap Color:*
    • Dacron Strap Color:*
    • Velcro Strap Color:*
    • Strap Placement:*
    • Lacer:
    • Lacer:*
    • Strap Options:
    • Strap Options:
    • Knee Pad Type:*
    • Image field 1339
    • Image field 1340
    • T Strap Placement:*
    • Calf Strap Width:*
    • Calf Strap Placement:*
    • Proximal Ankle Strap Width:
    • Proximal Ankle Strap Placement:*
    • Instep Strap Width:
    • Instep Strap Placement:*
    • Instep Strap Style:*
    • Instep Strap Style:*
    • Image field 1065
    • Image field 1069
    • Image field 1142
    • Add-Ons:
    • Add-Ons:
    • Add-Ons:
    • Non-Skid Surface:*
  • KAFO

    Notes
  • Your order will be sent to CDC after submission along with the Scan. No futher action is needed.

    (No Entry required at the LEO portal)

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  • Return Shipping Method:
  • Shipping is same as Billing Address:*
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Requested In-Office Date:
     - -
  • Daily HFN Capacity

  • {requestedInoffice}{requestedInoffice1489}{requestedInoffice1490}{requestedInoffice1491}

    • Requested In-Office Date: 
    • Image field 1494
    • Clinicians can still coordinate special in-office requests by emailing:
      HFN_Support@hanger.com

    • Today's Date:*
       - -
  • Should be Empty: